1821155128 NPI number — MODERN DENTAL PROFESSIONALS - INDIANA, PC

Table of content: (NPI 1821155128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821155128 NPI number — MODERN DENTAL PROFESSIONALS - INDIANA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN DENTAL PROFESSIONALS - INDIANA, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRIGHT NOW DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821155128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8415 DATAPOINT DR
Provider Second Line Business Mailing Address:
STE. 1020
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3298
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-578-6358
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 NORRIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH VERNON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47265-2343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-346-8000
Provider Business Practice Location Address Fax Number:
812-346-3990
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SINCLAIR
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-578-6358

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12010661A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com